Grass Valley Office 466 Brunswick Road Grass Valley, CA 95945 Tel: (530) 274-5601 Fax: (530) 274-5602 Toll Free: 866-577-6331 Quincy Office P.O. Box 4323 Quincy, CA 95971 Tel: (530) 283-6052 Fax: (530) 283-6368 Toll Free: 800-242-3338 Ext 6052 Website www.ns-pa.org Dear Provider Applicant,
Thank you for your interest in the IHSS Public Authority Provider Registry. Enclosed is an application packet for you to review and complete. Please read and follow the guidelines below so that we may process your application as quickly as possible.
Step #1
Complete the application packet. It includes:
Registry Provider Application – this is the 3 page application form to become an Independent Provider for Consumers who are on the In-Home Supportive Services (IHSS) program. Review, complete and sign.
Registry Provider Background form – this 2 page form gives us permission to contact your references and ask them job-related questions. Review, complete and sign.
Step #2
Mail or deliver the completed application packet to: Nevada-Sierra Regional IHSS Public Authority
466 Brunswick Road Grass Valley, CA 95945 Step #3
Participate in the Provider Orientation Training. Once your application has been processed, a Registry Specialist will call you to schedule an orientation.
Bring to your Orientation Appointment:
1. Any forms needed to complete your application packet 2. Current name and telephone numbers for your work and
personal references.
3. Your driver’s license and social security card or other forms of acceptable ID
4. Proof of current auto insurance (if you would like to drive as part of your provider duties)
Step #4
Be fingerprinted and pass a Live Scan background check. You must pay for your own Live Scan. The Public Authority will provide you with the proper forms, including a list of crimes that would exclude you from working for the IHSS program.
Please note that applying to the Registry does not guarantee your acceptance. If you have any questions please call us at (530) 274-5601.
We look forward to meeting you soon.
Registry Application
Independent Provider (IP)
First Name: Middle Initial:
Last Name: Email:
Home Phone: Cell Phone: Message Phone:
Mailing Address: City: Zip Code:
Drivers License: Exp Date:
Proof of Current Auto Insurance: Yes No Exp Date:
Days and Hours of Availability: (Check all that apply)
Mornings: Select All Mon Tues Wed Thurs Fri Sat Sun
Afternoons: Select All Mon Tues Wed Thurs Fri Sat Sun
Evenings: Select All Mon Tues Wed Thurs Fri Sat Sun
Overnight: Select All Mon Tues Wed Thurs Fri Sat Sun
Number of hours you would like to work per week ____________
Are you looking for a Live-In position? Yes No
About You Consumer Characteristics
Do you smoke? Yes No Will you work for a smoker? Yes No
How will you get to work?: Bus Car Do you have a preference who you work for? If yes please indicate.
Male Female
Do you read and write English? Yes No Will you drive a Consumer’s car for authorized tasks? Yes No
Will you use your car Yes No for authorized tasks?
Will you work with pets in the home? Yes No
Would you like to be referred to private pay Consumers?
Yes No Geographic Preference Nevada County Cedar Ridge Chicago Park Floriston Grass Valley Nevada City North San Juan Penn Valley Rough & Ready Lake of the Pines
Type of Work Desired Accompaniment to Medical Resources
Ambulation (assisting with walking, sitting, in/out cars etc.) Bathing - Oral Hygiene - Grooming
Bowel & Bladder Care: Full Care
Bowel & Bladder Care: Minimal Assistance
Care & Assistance with Prosthesis (cane, walkers, wheelchairs, back brace, etc.) Consumer uses Oxygen
Domestic Services (basic housecleaning duties) Dressing
Feeding (cutting up food, prompting to eat, assisting with eating Heavy Cleaning (authorized by IHSS social worker)
Meal Clean Up (dishes, wiping down counters, etc.) Menstrual Care (changing pads, etc.)
Moving In/Out of Bed Other Shopping & Errands
Paramedical Services (assisting w/ ace bandages, Band-Aids, med stockings, etc) Preparation of Meals
Protective Supervision (supervising an adult or child who can't be left unattended) Respiration (assisting w/ breathing treatments etc.)
Routine Bed Baths Routine Laundry
Rubbing Skin - Repositioning - Etc. Shopping for food
Willing to work with: Adults Children Development Disability Elderly Memory Problems Men Terminal Illness Women Languages Spoken
American Sign English French German Russian
Spanish Other
Applicant Ethnicity (Optional) African American Asian Caucasian Latino Native American Other
List any certificates or licenses you possess: (Copies of certificates need to be attached)
First Aid Expires: Expired CPR Expires: : Expired CNA Expires: : Expired CHHA Expires: : Expired
Please explain why you are interested in In-Home care:
How did you hear about us? Newspaper Radio/TV Word of Mouth
IHSS Social Worker EDD/CALWorks CUHW Union IHSS Provider Other
Church Flyer Training Phonebook
Independent Living Center Public Authority Website
I certify under penalty of perjury that all information on this form is true and correct to the best of my knowledge. I understand that any omission or misrepresentation of information on this form may disqualify me from being listed on the Registry. I give the Public Authority
permission to share relevant information in my file with individual consumers who are looking for providers. I understand that any false information may eliminate me from eligibility for participation on the Public Authority Registry.
I understand and give permission with regard to the above paragraph.
__________________________________________ _______________________
Registry Provider Background & References Release
Name: __________________________________________________________________
(Please Print) Last, First, Middle Initial
Other names you have used or been known by (maiden name): ___________________
________________________________________________________________________
Mailing Address: _________________________________________________________ City: ________________________________ State: _______ Zip: ___________ Contact Information: Please list phone numbers where you can be reached. Identify the type of
number such as home, cell, message. (One phone number is required)
Phone number_____________Type:_______ Phone number_____________Type:_______ Best times to reach me: _______________________________________________ _____
Male Female Date of Birth: ______ Social Security Number: _____________
________________________________________________________________________
References: Please list two work references and one personal reference. DO NOT USE FAMILY
MEMBERS.
Two Work References: List name of reference, Company Name, Telephone Number, position held
and number of years worked.
1. Name:___________________________Company______________Phone:__________
Relationship to Reference____________________Dates of Employment___________ 2. Name:___________________________Company______________Phone:__________
Relationship to Reference____________________Dates of Employment___________ 3. Name:___________________________Company______________Phone:__________
Relationship to Reference____________________How Long Known: ______________ ________________________________________________________________________
Background:
List the dates of residence and counties you have lived within the last ten (10) years:
List all Counties in which you have lived within the last 10 years:
County Start Date End Date Name Used
Have you been convicted of a felony or misdemeanor charge, or been on parole or probation? Failure to disclose this information will automatically disqualify you from acceptance to the Registry Yes No
If “Yes,” list all convictions in the last 10 years below. A “Yes” answer to this question does not
automatically disqualify you for the Registry. Each case is considered individually.
List the offense, date and place of conviction, sentence and date of release from custody and/or from probation/parole, and any other facts you want considered.
_____________________________________ _____________________________ _____________________________________ _____________________________ _____________________________________ _____________________________ _____________________________________ _____________________________ _____________________________________ _____________________________ _____________________________________ _____________________________
I certify under penalty of perjury that all information on this form is true and correct to the best of my knowledge. I understand that any omission or misrepresentation of information on this form may disqualify me from being listed on the Registry. I give the Public Authority permission to share relevant information in my file with individual consumers who are looking for providers, to contact any and all references, and to obtain any criminal background check information. I understand that any false information may eliminate me from eligibility for participation on the Public Authority Registry.
